The aphorism "the number of medications
used for this condition attests to nothing working"
may be applied at times to terminology: Psychogenic
seizure, Nonepileptic seizure, Pseudoseizure, Hysterical
epilepsy, Hysteroepilepsy, Hysterical seizures, Conversion
fits, Pseudo-attacks, Doxogenic seizures, Paroxysmal
somatoform disorder.

What is an appropriate non-prejudicial
term for patients who have phenomena that resemble
epileptic seizures but which are in reality psychogenically
induced? This is an active area of debate in neuropsychiatry
and epileptology. The number of terms suggested for
such a phenomenon is indicative of the difficult status
of such events in conventional medical terminology.

Two decades ago, clinicians were calling
these events hysterical epilepsy, hysteroepilepsy
or hysterical seizures. The term hysteria
then went out of favour in psychiatry and with it
hysterical seizures. Most common today is pseudoseizures
raising a new area of debate as to its appropriateness.
The events are not seizures hence the pseudo
component. However, they are not pseudo in that they
are extremely real episodes and pseudo implies a disparaging
element to the events. We agree with Trimble on the
pejorative inference on the nature of these episodes.
Patients feel badly, guilty, distressed or resentful
that their condition is perceived in a pseudo-artificially
-sense and that they are being actively accused of
causing it. Whereas this may or may not be true this
perception is unhealthy and inappropriate. Moreover
Slavney emphasizes the active role of the experient
in the pseudoseizure - they are doing it to themselves,
its not happening to them - in this way it is pseudo
but it has implications in primary and secondary gains
such as sick role and attention. Moreover, such events
are generally not consciously motivated: the patient
is not malingering his illness nor is it consciously
performed but for no apparent environmental gain -
factitious. Nonepileptic seizure followed but
this attempt to be neutral in connotation and acceptable
in denotation (Gates and Erdahl) fails because of
the inherent paradox in the terms. Psychogenic
seizurebecomes an alternative - again the term
seizure is controversial, although the psychogenic
nature of the event is emphasized. The term psychogenic
in psychiatry has become almost as unfashionable as
hysterical. Camouflage terms reflecting more non-prejudicial
frameworks yet emphasizing the connection with the
body has led to the whole area of Somatoform disorders
being studied. Merskey has suggested several other
alternatives. He emphasizes the conversion
nature of the events and suggests conversion fits
- the problem is it is inaccurate: whereas conversion
phenomena do occur, dissociative elements exist
as well. Moreover, we often refer to conversion in
the context of negative events - paralysis, mutism
and these are classically positive activities. Merskey
also suggests Doxogenic seizures. This introduces
the esoteric term, doxogenic, implying the
patients own mental conceptions and, in fact, Merskey
has also used the term in the multiple personality
disorder implying a common theme which is unproven
and probably unlikely - the two conditions do not
appear to markedly co-exist.

Can terms like epilepsy and seizures
be linked with pseudo or hysterical of somatoform
or conversion or some other equivalent? Not easily:
These events are not seizures so that the term
is inaccurate (Slavney). One cannot broaden the term
seizure to imply other paroxysmal events without
compromising the essential character of epileptic
firing in the brain. If it so broadened such events
as syncope and pain which involve non-epileptic short-lived
episodes of impaired consciousness, sensory perception
discomfort, or motor movements would be so incorporated.

This then restarts the debate on the
nature of seizures - whether we ought ot be limiting
the term to epileptic firing . Merskey alternatively
raised pseudo-attacks . This brings the debate
on pseudo back to the forefront and introduces a new
source of prejudice namely the attack. Is a
pseudoseizure an attack - if it's psychologically
induced is the patient the victim of the attack or
the cause of the action? Attack seems as prejudicial
as seizure. What terms can be used? We feel badly
about adding to this debate new terms but clearly
the old ones are unacceptable.

There is a need for a term describing
short-lived episodic phenomena of concern to the
patient or those around him - the term spell
accurately describes this. We feel the term ought
to be non-prejudicial for the patient, not
reflect episodic firing in the brain, allow for the
fact that numerous patients labelled pseudoseizures
actually turn out to have real though atypical
seizures on depth telemetry, and that real seizures
commonly co-exist in patients with pseudoseizures.
We want to emphasize the essential episodic nature
of the events which are usually sudden and
have onsets over seconds and usually last short time
- generally seconds or minutes occasionally hours
or days. Consequently they are paroxysmal. We and
others have used the term spell for a nonprejudicial
way to describe such paroxysmal attacks of altered
or impaired consciousness, behavior, emotions, perceptions
or motoric movements. We need to replace seizure with
something and spell seems more logical than somatoform
seizure for example. There is a major advantage to
using the term spell. Clusters of events can easily
be combined into a disorder or syndrome encompassing
the paroxysmal disorders. Spell is defined is paroxysmal
and delineates the episodic nature of the illness
and is particularly valuable considering our other
suggested related classification of Paroxysmal
Neurobehavioural Disorder. Spells imply that
these are happening as single discrete episodes in
time and moreover a series of spells of may ultimately
lead to a diagnosis of a syndrome or disorder cluster
e.g. Paroxysmal Somatoform Disorder (Blumer)
which may include also bodily episodes such as faints
or episodic pain or headache. Spells are non-prejudicial.
They do not imply seizure phenomena and yet do not
connote conversion, dissociation, hypochondriasis
or hysteroid behavior either.

Moreover, we want to link with conventional
DSM and ICD nomenclature, now and in the future.
We need to reflect conscious or unconscious behavior
of episodic bodily or mental kind non-prejudicially
and it would be worth having a term such as somatoform
- resembling bodily symptoms recently introduced into
psychiatric classifications. Indeed, one of us (DB)
has already suggested paroxysmal somatoform disorder
as a possibility.

The Somatoform element we believe to
be useful because it emphasizes the bodily symptoms
elements e.g. many of these patients have pain syndromes
such as headaches. Hence, Somatoform Spells
which would allow differentiation from syncopal or
pain episodes. People who have repetitive somatoform
spells would have SSD or Somatoform Spell Disorder.
We respectfully, therefore, add to the tumult of terms
this one.